Dietitian SOAP note example

A follow-up note for medical nutrition therapy with an adult who has type 2 diabetes. Many dietitians chart in ADIME, the Nutrition Care Process format; this note uses SOAP and puts the nutrition diagnosis, as a PES statement, in the Assessment.

Example SOAP note

Fictional client: Carlos G., 47, second medical nutrition therapy visit for type 2 diabetes, 45 minutes. Any likeness to a real person is a coincidence.

Subjective

Client reports swapping regular soda (3 cans a day) for sparkling water on weekdays; about 1 can a day on weekends. Now eats breakfast 5 days a week (oatmeal or eggs).

Dinner portion of rice is still "two big scoops." Walks 20 minutes after dinner 3 days a week.

24-hour recall: breakfast oatmeal with a banana; lunch turkey sandwich and chips; dinner chicken, about 2 cups of rice and salad; evening snack ice cream.

Medication per the chart: metformin 1,000 mg twice a day. Goals: lower his A1c and lose weight.

Objective

Weight 214 lb (97.1 kg), down 4 lb from 218 lb at the first visit four weeks ago. Height 5 ft 10 in (178 cm). BMI 30.7.

A1c 8.1% (from his primary care provider, three weeks before the first visit).

Fasting glucose log, last 10 days: 128–152 mg/dL (first week: 150–175 mg/dL).

Estimated intake from the recall: about 2,300 kcal and 280 g of carbohydrate a day, most of it at dinner.

Assessment

Type 2 diabetes (E11.9) with class 1 obesity (E66.811), BMI 30.0–30.9 (Z68.30).

Nutrition diagnosis: excessive carbohydrate intake at the evening meal related to large starch portions, as evidenced by about 2 cups of rice at dinner in the recall and fasting glucose above target.

Good progress: sugar-sweetened drinks down from about 21 cans a week to 2, weight down 1.8%, fasting glucose trending down. Client is motivated and already making changes.

Plan

Plate method at dinner: half non-starchy vegetables, a quarter protein, a quarter starch (about 1 cup of cooked rice).

Carbohydrate goal of about 45–60 g per meal; reviewed label reading for carbohydrates.

Swap lunch chips for fruit or nuts 3 days a week. Keep the after-dinner walks and add a fourth day.

Continue the glucose log and bring it to the next visit.

Follow up in four weeks. Ask his primary care provider for a repeat A1c at three months. Visit summary sent to the primary care provider.

Why this note works

  • A diet recall gives the Assessment something concrete to point to.
  • Weight, BMI, A1c and the glucose log are dated and compared with the first visit.
  • The nutrition diagnosis is a PES statement: the problem, its cause and the evidence.
  • Goals are specific and measurable (1 cup of rice, a fourth walking day), so the next visit can check them.
  • Coordination with the primary care provider is documented.

What to include in each section

Subjective

  • Diet history or 24-hour recall
  • Changes made since the last visit, and barriers
  • Appetite, GI symptoms, physical activity
  • Medications and supplements
  • Client's goals and readiness to change

Objective

  • Weight, height, BMI and weight change over time
  • Labs with dates (A1c, lipids, glucose log)
  • Estimated intake (kcal, carbohydrate, protein) and estimated needs
  • Nutrition-focused physical findings, if assessed

Assessment

  • Medical diagnoses with ICD-10-CM codes
  • Nutrition diagnosis as a PES statement (problem, related to, as evidenced by)
  • Progress toward goals since the last visit

Plan

  • Nutrition prescription and specific goals
  • Education given and materials provided
  • Monitoring: what to track before the next visit
  • Follow-up and coordination with the referring provider

Write yours with the free SOAP note template

The template opens with the dietitian prompts. Fill it in and download a PDF, made on your device.

Open the template

SOAP notes in CloudMedico

CloudMedico is practice management software for small practices. Choose SOAP as your visit note format in Practice settings, and every new visit's notes open with the headings Subjective, Objective, Assessment and Plan. Practices in the United States start with SOAP.

Add the visit's diagnoses from the ICD-10-CM list, and add your own visit fields for what your profession records every time, such as a pain scale or the regions treated. Each visit stays on the client's record with their appointments and invoices, and a US practice can make a superbill from the invoice.

Try CloudMedico free for 30 days

More SOAP note examples

Questions

Should dietitians use SOAP or ADIME?

Either can work. ADIME (Assessment, Diagnosis, Intervention, Monitoring and Evaluation) follows the Nutrition Care Process step by step. Many outpatient and private practice dietitians use SOAP, which other clinicians in the chart know well. Use what your setting expects.

What is a PES statement?

The nutrition diagnosis written as Problem, Etiology and Signs or symptoms: the problem, related to its cause, as evidenced by the findings. In a SOAP note it goes in the Assessment.

What does Medicare cover for medical nutrition therapy?

Medicare Part B covers medical nutrition therapy by a registered dietitian for diabetes and kidney disease, and after a kidney transplant, when a physician refers the patient. Most private insurers set their own rules.

Sources

Related